5 Features of a Sustainable, Integrated Health Care System

Many thoughtful leaders have taken strides toward creating a sustainable, patient-centred, integrated health care system but we’re not there yet.  Our patients, their families and evidence tell us there are opportunities for improvement. Through our front-line experience caring for 11,600 patients each day, we also know that to deliver quality home care, we need an integrated system that wraps care around the patient.

As in any sector, sustainable success is rooted in engaged teams effectively connected first through a common goal.  Health care is no different. As many leaders agree, form must follow function.

When I arrived to lead the Mississauga Halton Community Care Access Centre (CCAC) six years ago, this meant re-building a siloed organization. We fostered interdependent teams by connecting them with shared, measurable goals and a united vision. For Ontario’s health care system today, this means building an integrated system of care from the patient’s perspective outward.

If we start with structure, it is like planning a house without a location. You could well design a house that’s set to fall or flood, if you don’t know it’s going to be built on a cliff or levee. It’s also precarious to plan without full context in a fluctuating environment like ours, with its aging population and continual changes to support their rising needs, from funding reforms to new providers and evolving technologies.

To see the patient’s perspective, we need to step back and ask: ‘Why’ does the current system fall short of delivering an experience that consistently meets or exceeds expectations? Why is it not consistently responsive to patients’ and their families’ needs?

Using Home & Community Care to Overcome Obstacles

When I worked for more than 18 years in acute care, we knew that engaged and cohesive teams generated better outcomes for most patient populations.  We worked hard to involve physicians right up to the discharge door but that’s where our care ended.  To make way for those with time-sensitive, urgent needs, we discharged patients once they no longer required acute level care but sometimes before their post-discharge care was in place.

Then hospitals began to change how they delivered care and began moving alternate level care (ALC) patients to places better able to meet their needs.  Leaders saw community as an enabler to support this transformation and achieve their hospital’s goals. We also started to understand that patients and families wanted to remain at home and out of institutional care, as much as possible.

However, we had a blind spot to the role and impact of primary care physicians, nurses, allied health professionals, community service agencies and others in the continuum of care but beyond the hospital’s walls. We also had yet to realize the vital role of caregivers and families. Community was a disparate anchor. People moved back and forth between community and acute care, often multiple times a year.

Challenges in delivering consistent care experiences for our patients increased as the number of aging patients, with chronic and complex needs, rose. Without comprehensive capacity and program planning, our blind spot included socio-economic or cultural status obstacles that stopped patients from reaching their goals. It’s hard to heal when you can’t afford medication or have no means to safely travel to a clinic. Subsequently, a short hospital stay with an early discharge is detrimental when a patient returns less than 30 days later. Patients expect and deserve better outcomes.

In bringing care out of institutions and closer to patients’ homes, we shed light on these obstacles. Through meaningful conversations and assessment tools, home and community care went beyond clinical needs to identify social determinants of health that affect our patients’ care experience. We started to address these challenges through care coordination, which significantly reduces patients’ health risks, among other benefits. We also engaged families and set-up patients’ support services before they left hospital.

For Sam, a 66-year-old, frequent emergency department (ED) patient, who suffered from COPD, alcoholism, diabetes, hearing loss and depression, plus fear of eviction from a derelict apartment – healing was secondary. By the time Sam’s family physician referred him to CCAC, he was malnourished and in a desperate state. Our care coordinator had to first get him an accessible phone, re-channel his OPGT funds to pay his bills and fix his fridge. Once she addressed these necessities, she could set up medication management and coordinate his care plan.

Health care resources alone can’t meet all patient needs. Patients, like Sam, often need multiple partners at the community level, such as mental health and addiction services, volunteer or cultural groups, to play a complementary role in helping them reach their goals.  The challenge is our system’s design is incomplete. We have not intentionally designed a community care system to meet the needs of aging residents with complex needs. It doesn’t optimize the value of community-based services or integrate them to improve patient outcomes. In a more cohesive system, health care and community partners might have closely monitored Sam’s condition and alerted CCAC sooner. It might have also co-located services together, such as placing on site showers with personal support workers (PSWs) at Adult Day programs, with counselling nearby, to help patients like Sam achieve their goals.

Seeking solutions, we collaborated with the Mississauga Halton LHIN, Central West LHIN and Central West CCAC to develop a Community Capacity Plan in 2013. For this study, we contracted specialized health care consult support to assess our region’s health service needs now and the growing, future mandate. Results highlighted the importance of using patient assessments and information across the continuum of care to support population-based planning. These include Socio-Economic and Cultural (SEC) tools that can identify a neighbourhood’s needs, right down to those shared by people within the same postal code level or uncover areas where services are inequitably distributed.

The study’s findings also underscored the value that our current resources and best practices bring to our local system.

But to meet our residents’ expectations, we must resist the temptation to assess patient needs only through our lens. To design the system, we need to bring together data brought by clinical teams with patients’ and families’ expectations and goals.

That’s why our strategic plan is centred on understanding the patient’s voice. We need to listen and let it inform how we modernize the system or mobilize existing resources. By engaging our patients, through varied approaches, including our patient and caregiver advisory forum, we’re hearing about their needs.

Armed with insights from our patients and with our assets, we’ve lived a glimpse of this integrated vision through our seamless transitions: hospital to home approach. It reduced hospital readmissions in the first 30 days by 52 per cent in the pilot with Trillium Health Partners’ Medicine units and opened an opportunity to reduce ALC rates. In another example, we’re making great strides with Health Link. Through this provincial initiative, we’ve reduced the number of times patients with the highest needs visit the ED.

These programs prove that individual organizations, like our CCAC, can improve patient outcomes but not in silos.

Through this evolution of home and community care, our research and proven programs, I can envision a patient-focused, integrated health care system that:

1. Seamlessly works with multiple partners to identify and address socioeconomic impacts on neighbourhoods and their patients.
2. Recognizes care coordination as an essential health service for patients and supports its ongoing professional development to ensure consistent quality of care.
3. Stays informed and measured by evidence from our patients and their families’ voices, as well as data drawn from assessments and SEC tools, among others.
4. Collaboratively delivers care for patients at multiple levels, from patient and care coordinator partnerships to multidisciplinary partners, in acute, primary and long-term care, as well as mental health and addictions and community services.
5. Provides ongoing monitoring and adapts to patients and their caregivers’ changing needs.

In future posts, I will discuss these features in more detail, with global examples, as well as our tools, ongoing initiatives and results.

I believe we can collaborate virtually with our multidisciplinary and community partners to deliver comprehensive, dynamic care that reflects each patient’s current goals, journey and experience. This also means making each partner individually and collectively accountable for our patients’ well-being.

I welcome your thoughts and feedback.